The objectives
of this study were to verify the occurrence of urinary incontinence (UI) and
its characteristics in pre-frail and frail elderly patients of a geriatrics
outpatient clinic, compare the presence of frailness criteria among the elderly
with and without UI and identify among the frailty criteria the chance of risk
for UI among those elderly outpatients. Participants were 100 elderly individuals,
with an average age of 76.2 years; 65 participants reported UI, 71.3% of which
presented three or more frailness criteria. The occurrence of UI was greater
in frail participants (p=0.0011). Multivariate analysis showed that the criteria
slowness (OR=4.99) and exhaustion (OR=4.85) has a statistically significant
relation with UI. The occurrence of UI was high and participants who presented
slowness have a risk almost five times greater to presenting UI while those
reporting exhaustion have a risk five times greater for UI compared to those
without these criteria.

Urinary incontinence
(UI) has been little investigated by health professionals and studies addressing
its prevalence and incidence are scarce in Brazilian literature(1)
despite the fact researchers indicate it as a public health problem(2).

UI is defined as
any involuntary urine loss(3). It is a frequent condition
in the population in general, affecting approximately 19% of women and 10% of
men older than 60 years of age. Its occurrence increases exponentially as age
advances due to functional and structural changes occurring in the urinary system
and with impaired functional independence. Hence, it is estimated that with
the growth of the elderly population, the occurrence of UI will increase considerably,
as well(2-3).

International studies
show that UI affects approximately 30% of the elderly individuals living in
the community, 40.0% to 70.0% of those hospitalized and 50.0% of those institutionalized.
It represents a great economic burden as it encumbers financial resources related
to care and expressively increases the risk of institutionalization, frailty,
fractures and depression(3). Additionally, UI is considered one of
the most important and recurrent geriatric syndromes(4-7) as it impacts
multiple aspects of the lives of elderly individuals. Negative implications
at the emotional, social and economic levels deserves attention because these
affect both the incontinent individual and his/her family and caregivers(1).
Evidence from research indicates that UI is an early sign of pre-frailty and
frailty in the elderly individual. It is also associated with an increased risk
of functional decline(8-9).

The term frailty
related to elderly individuals was rarely mentioned before the 1980s. It referred
to a weak elderly individual with a cognitive and physical deficit, disabled,
sick and living in unfavorable socioeconomic conditions. A consensus has not
been reached on the definition and identification of frailty as a syndrome,
which represents one of the major obstacles for clinical research(10).
However, two streams of research are more consolidated than others. Among the
scholars who study frailty as a syndrome among elderly people, the research
group coordinated by Linda Fried(11) in the United States stands
out. This group proposed a list of objective and measurable criteria that compose
a one-dimensional frailty model, considering the physiopathological aspects
of the syndrome to be a priority. The research group of Kenneth Rockwood in
Canada also stands out. The group considers frailty to be a multidimensional
syndrome, including social, psychological, biological and economic aspects and
emphasizes the complexity of its etiology that composed this model, proposing
the use of frailty indexes developed based on a comprehensive geriatric evaluation(10).

Currently, one
of the most accepted definitions is that frailty is a syndrome characterized
by reduced energy reserves and diminished resistance to stressors(11).
Three physiological changes related to age subjacent to the frailty syndrome
occur. These are known as tripod frailty: neuromuscular disorders, endocrine
and immune system dysfunctions(11).

Based on these
alterations, researchers of the one-dimensional frailty model developed a phenotype
of frailty composed of five criteria: unintentional weight loss in the last
year, exhaustion, slowness, muscle weakness, and a low level of physical activity(11).
To be considered frail, an elderly individual needs to present three
or more criteria of the phenotype. The presence of one or two criteria characterizes
pre-frailty, given the high risk of developing the frailty syndrome(12).
The early identification of frailty criteria is important given that preventing
adverse events such as decompensation of chronic diseases, falls, institutionalization,
disability and death(12). Additionally, studies show that in this
pre-frailty phase, frailty can be avoided(8).

A literature review
revealed a scarcity of studies addressing UI in elderly individuals presenting
frailty criteria. Hence, the relevance of this study is related to the need
to verify this occurrence, considering that UI can be a sign of frailty syndrome,
which in turn is a public health problem.

OBJECTIVES

 To verify
the occurrence of UI and its characteristics in pre-frail and frail elderly
individuals cared for in a geriatric outpatient clinic.

 To compare
the presence of frailty criteria among elderly individuals with and without
UI

 To identify
among the frailty criteria the risk for the occurrence of UI in these elderly
individuals.

METHOD

This quantitative,
descriptive and cross-sectional study was carried out in the Geriatric outpatient
clinic of the Hospital das Clinicas at the State University of Campinas (Unicamp).
The outpatient clinic is located on the third floor and its multiprofessional
team delivers care on Thursday afternoons to elderly individuals 80 years old
or older or older than 60 years with physical and cognitive dependencies.

Data were collected
from February to August 2009 with a convenience sample composed of 100 elderly
individuals cared for in the outpatient clinic and who met the following inclusion
criteria: minimum age of 60 years old; consent to participate in the study after
signing free and informed consent forms; being able to communicate; score in
the Mini-Mental State Examination (MMSE) > 13 (for illiterate individuals),
> 18 (1 to seven years of schooling), > 26 (8 or more years
of study) (13) and who presented at least one of the five frailty
criteria of the one-dimensional frailty model(11). The following
exclusion criteria were used: elderly individuals with impaired communication,
cognitive deficits or scores in the MMSE below those mentioned in the inclusion
criteria and absence of frailty criteria adopted in the study.

The one-dimensional
frailty model was used to evaluate frailty(11). The model is composed
of the five criteria described earlier. For that, three of the criteria needed
to be adapted because at the time when the instrument was developed (2002) for
a thematic project, there was no detailed information about the evaluation procedure
of each criterion. Hence, similar to other studies found in the literature,
we attempted to adjust the criteria of this study to those published later by
researchers of this model, as follows:

 Unintentional
weight loss in the previous year: a positive score was attributed in the event
of weight loss above 4.5 kilograms or more than 10% of body weight in the previous
year. The original model classifies weight loss above 5% of body weight;

 Exhaustion:
evaluated by two questions in the Center for Epidemiological Studies Depression
Scale (CES-D) to detect the number of times in the last week the interviewee
felt s/he had to make an extra effort to be able to perform routine tasks
and I could not get going(14). A positive score was attributed
if the answers for both were affirmative for three or more days in the previous
week according to the original model.

 Slowness:
evaluated by decreased walking speed, that is, the time spent to go around a
distance of four meters twice, adjusted by gender and height as measured; the
lowest time was selected. Results equal or above seven seconds for men with
a height below or equal to 173cm and six seconds for men with a height below
173 cm were scored. For women, results above or equal to seven seconds for those
with a height below or equal to 159cm and more than six seconds for those with
a height above 159cm were scored. The distance used in the original model was
4.5 meters.

 Muscle weakness:
assessed by grip strength, measured through a portable manual dynamometer in
the dominant hand, with the elderly individual in a standing position. The highest
value of three measures taken in an interval of about five minutes among them
was used. The results were stratified by gender and body mass index (BMI). Scores
were assigned according to the criteria presented in Chart
1.

 Low level
of physical activity: the participants were asked whether they practiced physical
activity and with what frequency. A score was assigned in the case of negative
response or if the frequency was once or twice a week. In the original model
the participants weekly energy expenditure is assessed based on the self-reporting
of activities or physical exercise evaluated by the Minnesota Leisure Time Activities
Questionnaire and adjusted according to gender.

Data were collected
through structured interviews using the following instruments: 1) socio-demographic
characterization to collect information related to the sample characterization.
The instrument was evaluated for content validity and evaluated by a panel of
four experts in the fields of geriatrics and gerontology, as well as in the
field of UI, to assess its adequacy for the study; 2) The International Consultation
on Incontinence Questionnaire-Short Form (ICIQ-SF) was used to evaluate UI.
It was an adapted and validated for Portuguese from Brazil(15). (ICIQ-SF)
is composed of six questions, which evaluate the frequency and severity of urinary
loss and how much UI interferes in daily life. It also presents a sequence of
eight self-diagnosis items related to the causes or situations of UI that are
not scored. The sum of scores (ICIQ score) of questions three, four and five
vary from 0 to 21. Interference of UI in daily life is defined according to
the score of question five: (0) nothing; (1-3) a little; (4-6) moderately; (7-9)
severe; (10) very severe. To be considered incontinent, the elderly individual
should present a score equal to or above three; the higher the score, the greater
the UI severity(15).

After the evaluation
of elderly individuals concerning frailty according to the criteria adopted
in this study, two groups were obtained: one with 41 (41.0%) individuals meeting
one or two criteria were considered pre-frail and another group composed of
59 (59.0%) individuals meeting three or more criteria were identified as frail.

Statistical analyses
are described as follow:

 Descriptive
analysis for socio-demographic variables for the ICIQ-SF scores and frailty
criteria;

 Cronbachs
alpha to evaluate internal consistency of the ICIQ-SF instrument. This coefficient
is used to verify the homogeneity of items, that is, its accuracy. The Cronbachs
alpha for the ICIQ-SF was considered satisfactory with a value 0.84 for the
question three, 0.86 for question four, 0.88 for question five and the weighted
Cronbachs alpha was 0.89 (satisfactory criteria á ? 0.70)(16).

 Chi-square
test or Fishers exact test were used to compare elderly individuals with
and without UI and frailty criteria.

 Univariate
Logistic Regression and Multivariate analysis was used to study the relation
between UI and frailty criteria.

The level of statistical
significance adopted for the tests was 5%, that is, p<0.05.

This study integrates
the thematic project entitled Quality of life in elderly individuals: indicators
of frailty and subjective wellbeing submitted to and approved by the Research
Ethics Committee at FCM-UNICAMP (protocol CEP 210/2003) and an addendum related
the UI evaluation (protocol CEP 240/2003).

RESULTS

A total of 143
elderly individuals were cared for in the Geriatric outpatient clinic during
the data collection period, 100 of which met the inclusion criteria. As presented
in Table 1, the predominant characteristics of the sample
were: women (74%); older than 70 years of age (78.0%) average of 76.6 years
(±7.8); originated from Campinas (54%) and low level of schooling (49.0%).

A total of 65.0%
of the interviewed elderly individuals reported involuntary urine loss. They
obtained scores equal to or above three in the ICIQ-SF, which means they reported
urinary loss once or less a week in small quantities. Of the total of 65 elderly
individuals with UI, 40 (61.4%) reported urine loss several times a day and
in small quantities. The score regarding the impact of UI on the daily lives
of elderly individuals, evaluated by question five of the ICIQ-SF, varied from
zero to ten (average 4.85) and almost half of the individuals (49.2%) consider
it very severe (Table 2). The main causes or situations
in which urine loss occurred reported by the 65 elderly individuals were before
reaching the bathroom (50%) and when coughing or sneezing (37%).

A statistically
significant difference (p=0.001) was found in the comparison between elderly
individuals with and without UI and frailty criteria in relation to the number
of criteria: 62.8% of the individuals without UI presented one to two criteria
(pre-frail) while 70.7% of the individuals with UI presented three or more criteria
(frail). Hence, elderly individuals with UI scored in regard to a larger number
of criteria of frailty when compared to elderly individuals without UI.

All the criteria
adopted in the study presented significant differences between elderly individuals
with and without UI with exception of involuntary weight loss in the previous
year. The criteria low physical activity and slowness were the
criteria most commonly met by both elderly individuals with and without UI,
88.0% and 65.0% respectively. There was a larger number of elderly individuals
with UI, amounting to a statistically significant difference (Table
3).

Since the comparison
between the groups with and without UI and the frailty criteria presented statistically
significant differences, Univariate and Multiple Logistic Regression was performed
to investigate the relation between UI and frailty criteria as presented in
Tables 4 and 5.

The results of
the Multivariate Analysis with Stepwise criterion for variable selection indicated
that the criteria slowness and exhaustion were statistically significant,
that is, the elderly individuals who presented decreased walking speed presented
a risk five times greater of having UI (OR=4.99) and those who presented exhaustion
had a risk approximately five times greater of having UI compared to those who
did not (OR=4.85).

DISCUSSION

The occurrence
of UI was 65% in the studied sample. This is much higher than that described
in the national and international literature, especially among elderly individuals
in the community. It still is close to the results of studies conducted with
institutionalized elderly individuals. A study conducted in São Paulo,
SP, Brazil with 2,143 elderly individuals in the community is highlighted. The
researchers found an occurrence of UI in 11.8% in men and 26.2 in women(17).
The occurrence of UI was 33.3% among elderly individuals with dementia cared
for in an outpatient clinic(18). These are considered frail by the
very nature of their diagnosis. On the other hand, in samples of more vulnerable
elderly individuals, that is, in follow-up or institutionalized, situations
that precede the onset of the frailty syndrome, these values increase(4).
UI in frail elderly individuals is a syndromic model with the interaction of
multiple risk factors such as psychological and cognitive alterations related
to age and comorbidities(9).

There is no consensus
in the literature in relation to the UI characteristics such as frequency and
quantity of urinary loss since these are a consequence of several factors: type
of UI, the individuals health condition, comorbidities, and degree of
functional dependency, among others. In this study, 61.5% reported urine loss
several times a day in small quantities. Similar results were obtained in a
study with institutionalized elderly women. In an international study, the authors
reported results in which 31.8% of elderly women lost urine several times a
day(19). Another study performed in Hong Kong with 148 elderly individuals
in outpatient follow-up showed that 16.7% of the individuals reported urine
loss less than three times a week, 12.5% daily and 4.2% from three to six times
a week(18).

The impact of UI
in daily life was considered by most participants to be very severe, despite
the predominance of reports of small quantities of urine loss. The same was
found in an international study where 81.0% of the individuals reported a great
impact on quality of life due to urine loss(18). This loss is a negative
form of interference in the daily lives of individuals related to loss of independence
in attending family parties, church, to shop for groceries, among other activities,
given shame and the fear of losing urine and exuding characteristic odors(20).

The most frequent
situations in which urine loss occurred were: before reaching the bathroom
and when exerting effort suggesting the presence of urge incontinence
and effort urinary incontinence in most of the interviewed individuals, confirming
national and international findings concerning the most common types of UI in
old age. The main cause of urge incontinence is related to the increased frequency
of detrusor hyperactivity, according to studies addressing urodynamic testing
in elderly individuals(18).

The results revealed
that the incidence of UI in pre-frail and frail individuals is expressive since
65% of the 100 participants with frailty criteria presented UI. The presence
of UI was more common among those with three or more frailty criteria when compared
to those who presented up to two criteria. It suggests that as the number of
frailty criteria increases, there is an increased risk for the development of
UI.

Among the frailty
criteria, the Multivariate Logistic Regression showed statistical significance
for the criteria slowness and exhaustion, that is, elderly individuals
with slowness have a five times greater risk of having UI compared to those
that do not present slowness and elderly individuals with exhaustion have a
4.9 times greater risk of having UI compared to those who have not. Studies
describing the presence of UI in elderly individuals with frailty criteria are
scarce in the literature, however, the frailty tripod(11)
indicates that neuromuscular alterations related to age are subjacent to the
frailty syndrome(8,12) and slowness is associated with mobility alterations
that can hinder an individuals access to the bathroom and favor the occurrence
of UI, especially urge incontinence(11). Many studies present association
between UI and mobility in elderly individuals(17-18).

Additionally, slowness
has a close relationship with physical activity and can be either a consequence
of reduced physical activity or its cause. Studies indicate that reduced physical
activity can be a factor of the onset of UI in frail individuals(8),
hence the maintenance of physical activity may delay the onset of UI in this
population. Once this reduction is already established, one needs to undergo
physical rehabilitation to improve this condition and prevent the development
of UI. The authors of a study conducted in Japan reported a significant rate
of cure of UI among elderly individuals with UI who have undergone treatment
utilizing physical exercise and who have improved their walking speed(21).
In relation to exhaustion, it is believed that this condition can contribute
for UI as it can cause discouragement and a lack of motivation to go to the
bathroom.

The results of
this study emphasize the need to implement practical measures to improve muscle
strength, and consequently reverse the trait of slowness, such as exercises.
Additionally, measures such as strengthening the pelvic floor muscles and behavioral
changes related to food, fluid intake and urinary elimination habits are strategies
that favor reducing urge incontinence and effort UI, the most frequent types
found in this study.

In the same way
frailty can result in death, UI is associated with an increased risk of mortality
among elderly individuals(22). Therefore, the International Continence
Society recommends that UI be investigated in all elderly individuals meeting
frailty criteria(9).

Given the results
obtained, the contribution of this study is to support the development of intervention
strategies by the health team, to recover from and prevent diseases. Pre-frail
individuals are less incontinent, which indicates the need to plan early actions
to prevent UI and the frailty syndrome. Reversing these conditions can consequently
reduce economic, social and psychological burdens.

CONCLUSION

The incidence of
UI in this studys elderly individuals was high (65%) and the most frequent
complaint was urinary loss in small quantities and several times a day. With
the exception of the criterion involuntary weight loss, all the frailty
criteria presented a statistically significant relationship with UI among those
meeting frailty criteria; individuals who presented slowness have a five times
greater risk of having UI and those who present exhaustion have almost a five
times greater risk of having UI when compared to those individuals who did not
present any of these criteria.

This study has
some limitations, such as the fact that a detailed assessment of weekly energy
spent through the Minnesota Leisure Time Activities Questionnaire was not possible.
Because this is a cross-sectional study, conducting a longitudinal study to
monitor elderly individuals with UI would be interesting to verify whether these
would develop the frailty syndrome.

UI assessment was
performed through the ICIQ-SF. Even though this is an established instrument
widely used in the literature for such purposes, UI evaluation should not be
limited to it. Other aspects should be also considered such as anamnesis, specific
and general physical assessments, aspects from a neurological and genitourinary
point of view, and the performance of other specific evaluations for UI, including
voiding diaries and urodynamic evaluations.